Health Plan Operations Manager (Call Center Audit Lead) LOCALS PREFERRED - Raag Solutions : Job Details

Health Plan Operations Manager (Call Center Audit Lead) LOCALS PREFERRED

Raag Solutions

Job Location : New York,NY, USA

Posted on : 2025-08-16T00:57:34Z

Job Description :

LOCALS PREFERREDSHOULD WORK IN W2

  • We are seeking a highly skilled and experienced professional to join our team as a Health Plan Operations Audit Expert with a specialization in Call Center and Claims Integrity Auditing for Medicare/Medicaid SNP (Special Needs Plan) claims.
  • This role is critical in ensuring compliance with regulatory requirements, maintaining claims accuracy, and optimizing operational efficiency within our organization's health plan offerings.

Qualifications:

  • Bachelor's degree in Healthcare Administration, Business Management, Finance, or related field; Master's degree preferred.
  • Extensive experience (5+ years) in health plan operations, claims management, or auditing, with a focus on Medicare and Medicaid SNP claims.
  • In-depth knowledge of Medicare and Medicaid regulations, policies, and procedures governing claims processing and billing.
  • Proven track record of developing and implementing audit protocols, methodologies, and quality improvement initiatives.
  • Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA)) preferred.

Responsibilities:

Claims Integrity Audit Management:

  • Lead and oversee all aspects of claims integrity auditing processes for Medicare and Medicaid SNP claims.
  • Develop and implement audit protocols, methodologies, and procedures to ensure comprehensive coverage and accuracy assessment.
  • Conduct regular audits of claims data, documentation, and processes to identify discrepancies, errors, and areas for improvement.
  • Collaborate with internal stakeholders, including claims processing teams, compliance officers, and data analysts, to address audit findings and implement corrective actions.

    • Regulatory Compliance Assurance:

  • Stay updated on Medicare and Medicaid regulations, guidelines, and requirements related to SNP claims processing and billing.
  • Interpret and apply regulatory standards to audit processes and ensure compliance at all stages of claims handling.
  • Provide guidance and support to operational teams to align processes with regulatory expectations and minimize compliance risks.
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